Dual antiplatelet therapy pretreatment in patients undergoing intravenous thrombolysis for acute ischemic stroke: a systematic review and meta-analysis of 296,854 patients.

PURPOSE Wea im to evaluate the impact of Dual Antiplatelet Therapy (DAPT) pretreatment on outcomes in patients with Acute Ischemic Stroke (AIS) undergoing intravenous thrombolysis (IVT).

METHODS A systematic search was conducted from inception to January 2025. Eligible studies included randomized and observational cohorts comparing AIS patients with and without DAPT pretreatment who underwent IVT. Primary outcome was favorable functional outcome at 90 days (mRS 0-1). Secondary outcomes included mRS 0-2, mRS 3-6, in-hospital and 90-day mortality, and symptomatic intracranial hemorrhage (sICH) defined by SITS-MOST, ECASS II, and NINDS criteria. Risk of bias was assessed using the ROBINS-I tool, and meta-analyses were performed with random-effects models.

RESULTS Eight studies including 296,854 patients (61,925 with DAPT and 234,929 without DAPT) were analyzed. DAPT pretreatment was not associated with favorable functional outcome (mRS 0-1; OR: 1.03; 95% CI: 0.92-1.16; p = 0.57; I2 = 0%), in-hospital mortality (OR: 1.00; 95% CI: 1.00-1.00; I2 = 0%), or 90-day mortality (OR: 1.49; 95% CI: 0.99-2.25; p = 0.06; I2 = 52%). No significant increase in sICH was observed using SITS-MOST (I2 = 64%) or ECASS II (I2 = 63%), whereas sICH defined by NINDS was increased (OR: 1.31; 95% CI: 1.19-1.44; p < 0.01; I2 = 48%), corresponding to a 1% absolute risk increase (RD: 0.01; I2 = 0%).

CONCLUSION Prestroke DAPT was not associated with favorable functional outcome or reduced mortality after IVT and was associated with a higher risk of sICH when defined by NINDS criteria, with a 1% absolute risk increase.